Payment Not Received Inquiry

Payment Inquiry

Submit this form if you have not received payment from The HelpCard Chicago office. Please provide accurate information to help us review your inquiry. Any false information submitted will be subject to denial of said claim, AND will be subject to legal actions.
Company / Individual Name
Contact Person Name
Relationship to The HelpCard Chicago (e.g., vendor, former staff, contractor, landlord, partner agency)
Email Address
example@example.com
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Mailing Address

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
Invoice / Reference Number(s)
Description of Services Provided
Date(s) Services Were Provided

MonthDayYear
Date
Total Amount Owed (USD)
Supporting Documentation (invoices, contracts, statements, timesheets, etc.). * IF YOU ARE A FORMER EMPLOYEE, PLEASE PROVIDE YOUR EMPOLYEE ID NUMBER ! *

Cancelof
Preferred Method of Contact
Certification: I certify that the information provided is true and correct and that payment has not been received from The HelpCard Chicago for the amount claimed.
Name of Authorized Signer
Title of Authorized Signer
Signature
Date Submitted

MonthDayYear
Date
Additional Information : Please keep in mind that this is the process. All information received will be forwarded directly to the Appropriate Legal Counsel for Payment Consideration.
Should be Empty:

Payment Inquiry